Death of new-borns and the Kerala model

P N Venugopal

24 May 2007

- The death of 38 new-borns from a hospital-acquired infection at the Sree Avittom Tirunal (SAT) Hospital in Thiruvananthapuram over the past four months has shocked Kerala. All the deaths were in the neonatology unit of the hospital where 60 deliveries on an average take place daily. The incident has set the alarm bells ringing as it has happened in Kerala, which boasts of the lowest infant mortality rate in the country with only 15 deaths per thousand where as the national average is 58.

The first three infection-caused deaths were reported in January. The count went up steadily with five in February, 14 in March and 16 in April. It was only then that the media zoomed in and the hullabaloo broke out. The hospital superintendent Dr K Rajmohan was placed under suspension for not reporting the deaths and the cause to the higher authorities. Politicians of all hues made a beeline to the hospital and the opposition demanded that Rs.10 lakhs be paid to the parents of each baby that died.

"It's a system failure, a classic case of negligence and wrong health policies," says Dr Ramesh, Secretary of the Kerala branch of the Indian Medical Association.

The government setup a five member expert committee to investigate the deaths. Dr V Rajasekharan Nair was the Chairman and Dr Sudhayakumar, Director of Medical Education, was the convener. The committee confirmed in its interim report that there was an outbreak of sepsis in the in-born nursery (IBN) at the hospital which led to an increased proportion of babies dying due to infection. However, there was no apparent increase in the total mortality rate of the babies admitted to the SAT Hospital's IBN, the report said. The hospital authorities were aware of an increased rate of infection in its IBN and had adopted measures to contain the infection. The report found that the labour room and theatre cots at SAT are cleaned and wiped with anti septic solutions after each case.

But these efforts proved to be ineffective. Time for air drying is not there and as the next patient is ready to occupy the cots. Lack of staff has resulted in the same person doing multiple jobs, including handling of babies. Also, the concerned sites of infection could not be closed down and the babies shifted to an alternate nursery, the report said. It added that the principles of 'barrier nursing' should have been implemented. It recommended that further admission to the present IBN be stopped and that once all babies are discharged, it should be properly disinfected and fumigated. Babies not requiring critical care should be kept with the mothers, said the report.

Despite this, the interim report surprisingly attempted to explain away the deaths. According to the committee, the deaths of new-borns in March and April were proportionate to the rise in number of admissions during these months. The report reeled out statistics to prove that the number of deaths were not all that alarming. However, even if we take the report on its face value, the tragedy throws up many serious questions.

Why is it that this 'women and children' hospital with 1035 beds is overcrowded round the year, with the average number of inpatients being 1200? And why almost double its capacity during March and April? Why only two nurses per shift in the IBN when there are 60 new-borns to take care for? Why is it that the hospital which had spent one crore rupees for modernisation in 2006 doesn't have space or facilities for an alternate IBN when more than 20,000 deliveries take place a year in the hospital?

Inquiry into these questions reveal that the much discussed and extolled Kerala model of health development is ailing and on the decline. The third National Family Health Survey (NFHS) in March 2007 shows that Infant Mortality Rate (IMR) in urban Kerala has increased to 18, from 16 in the second survey (1998-99). The percentage of children between 12 and 23 months who have received all recommended vaccines have declined to 75 percent from 80 percent. The percentage of children under three years who are underweight has gone up from 27 to 29 percent. (Apart from the 38 babies who died due to infection, there were 63 other infant deaths at the SAT Hospital from January to April and many of them were underweight.)

Here is one data which is bound to have direct bearing on those deaths. Anaemia during pregnancy in women of 15-49 years went up from 20.3 percent in 1998-99 to 33.1 percent in the recent survey. The beginning of a downward trend in general health is indicated by these statistics.

Diseases like Malaria and TB were thought to have been eradicated. Not only have they made a come back, but hitherto unheard of diseases like Dengue fever, Japan Encephalitis and Chickun Gunya, apart from AIDS, have emerged on the scene. Chickun Gunya had caused a huge scare last year affecting thousands in Alappuzha district and elsewhere in the state. Lifestyle diseases like diabetes, heart problems, high blood pressure are on the increase, according to the KSSP.

The first phase of health care resulted in the in the increase of life expectancy, but it also means that the number of the aged too are increasing. A study done by Kerala Sastra Sahitya Parishad (KSSP) had predicted years ago that by 2025, 20 percent of Kerala's population will be above the age of 60. Add to it the constant migration of the young to other states and to foreign countries, and Kerala could be saddled with a large proportion of sick people. If morbidity declined in the first phase, it is showing all signs of increasing in the second stage that has never really taken off.

Kerala has had a unique place for years in any health index table. In growth of population, infant mortality and life expectancy, Kerala compared very favourably with the national averages. "Good health at low cost" was the motto of Kerala, as Dr B Ekbal, National Convener, Jan Swasthya Abhiyan puts it. The process started half a century ago, when the ground situation was abysmal. In 1957-58, the state's expenditure on health was 8.48% of total revenue expenditure, compared to the all-states average of 4.36%. This continued even in the 1980s when Kerala was in the grip of severe financial crisis. And by the middle of that decade, each village had a primary health centre and there was a chain of government hospitals at the Taluk and district level apart from medical colleges and Ayurveda and Homoeopathy hospitals. And the rise in literacy, especially female literacy helped.

The broad public health infrastructure exists even now. But debilitated and dilapidated. Many hospital buildings are in near ruins, the premises cluttered with bushes and waste materials, the wards over flowing with patients, toilets stinking, X-ray machines not working, the laboratories not having essential kits...Worse, no medicines in the pharmacy, one doctor where three are required and one nurse where four are required. "Poor hygienic conditions, lack of infrastructure, and deficiency of doctors and nurses plague all government hospitals," confirms Ramesh.

The rot had set in even before the forces of globalisation started sweeping the country in early 1990s. The Ekbal Committee (headed by Dr B Ekbal) appointed by the government in December 2006 to study the working of government medical colleges says that while the period from 1966 to 1985 was a "phase of achievement", that from 1986 to 2000 was one of "decline" and the post 2000 years a time of "degeneration". The report further says that the routine practice of medicine went through dramatic changes from the mid eighties, with newer equipment and techniques coming into the field. But the government medical collages lagged behind in adapting to the changes. Doctors trained in new technologies then started preferring the work in private hospitals. Ramesh holds the successive governments that have ruled the state over the last two decades responsible for the state of affairs.

The gradual withdrawal of the government from public health is all too visible. The expenditure on health as percentage of total revenue expenditure, which was 9.61 in 1960-61, came down to 7.53 in 90-91 and 5.67 in 2001 and 6.3 in 2005-06 (Economic Review 2006) whereas the World Health Organisation recommends 13 to 15 percent as desirable. This is in spite of the fact that the population of Kerala which was 291 lakhs in 1991 and grown to 318.4 lakhs in 2001, must have been at least 331 lakhs in 2005-06, an increase which demands higher allocations in the natural course. The over populated, understaffed and emaciated hospitals are a direct result of this callous treatment and negligence.

This change in the accent inevitably led more and more people to the doors of private hospitals which grabbed the opportunity and mushroomed. According to KSSP, even among the poorest, nearly 40 percent relies on the private sector. The exodus to the private sector has made the authorities all the more complacent. The infant mortality rate has been hovering around 15 for almost a decade now. There has not been any concerted effort or perhaps even a desire to reduce it further to the level of the developed countries like Germany and the USA where the rate is only 4 per thousand. It is also strange that the state does not have a declared health policy.

Coming back to the issue of infant mortality at the SAT Hospital, the Ekbal Committee has reported that usual hygienic measures are not enough to tackle the problem of hospital infections. They have suggested that each institution should have an 'antibiotic policy' to prevent hospital infections. Ramesh adds that instead of confining to fire fighting during a crisis, the government should have a long term perspective. "All major hospitals like the SAT should be made referral hospitals after strengthening the peripheral infrastructure. The Primary Heath Centres and the Taluk level hospitals should be well equipped so that only the complicated cases need go to the major hospitals," he says.

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In what appeared to be a case of publicity-seeking, V Vikraman, a BJP activist filed a complaint against the health minister P K Sreemathy and hospital staff. An enthusiastic magistrate of a local court, S Gopalakrishnan, asked the police to register a case against Sreemathy on the charge of culpable homicide not amounting to murder.

Diseases like Malaria and TB were thought to have been eradicated. Not only have they made a come back, but hitherto unheard of diseases like Dengue fever, Japan Encephalitis and Chickun Gunya, apart from AIDS, have emerged on the scene. Chickun Gunya had caused a huge scare last year affecting thousands in Alappuzha district and elsewhere in the state.